Dental Caries experience among qat chewers in Jazan population, Saudi Arabia

doi:10.21203/rs.3.rs-2345387/v1

Aims

There is a considerable debate on the impact of qat chewing on dental and oral health. Thereby, this study aimed at assessing the dental caries among qat chewers (QC) in comparison to non-qat chewers (NQC) in Jazan region, Saudi Arabia

Materials and Methods

A sample of 100 QCs and 100 NQCs were recruited amongst those attended dental clinics, college of dentistry, Jazan University during the 2018–2019 academic year. Their dental health was assessed by three precalibrated male interns using DMFT index. The Care Index (CI), Restorative Index (RI) and Treatment Index (TR) were calculated. Comparisons between both subgroups were done using independent t-test. Multiple linear regression analyses were further conducted to stand on the independent determinants of the oral health among this population.

Results

QCs were unintentionally older (36.55 ± 8.74 years) than NQCs (32.96 ± 8.49 years; P = 0.004). Fifty-six percent of QCs reported brushing their teeth compared to only 35% (P = 0.001). More QCs were of higher educational levels compared to NQC. The mean Decayed [5.91 (5.16)] and DMFT [9.15 (5.87)] were higher compared to NQC [3.73 (3.62) and 6.7 (4.58); P = 0.001 and 0.001, respectively]. The other indices were not different between both subgroups. The multiple linear regression revealed that qat chewing and age, individually or together, as independent determinants for the dental decay, missing, DMFT and TI.

Conclusion

Qat chewing habit has a detrimental impact on dental health. It is associated with higher dental caries and missing teeth, and a lower treatment index.

Qat, also known as khat, chat, miraa, murungu and Arabian or Abyssinian tea, is an evergreen shrub belongs to the Celastraceae family, and scientifically called Catha edulis [1]. It is cultivated, and even wildly grows, in some African countries and southwest of the Arabian Peninsula [1, 2]. The habit of qat chewing is a deep-rooted cultural habit in these areas [3]. Qat chewing is known to produce an amphetamine-like stimulating effect, and that is why it is habitually chewed [4]. The session of qat chewing lasts several hours. Briefly, the fresh leaves and twigs of qat are chewed to form a bolus which kept on one side of the mouth and continually chewed to release the qat extract which swallowed and/or absorbed through oral mucosa [3, 5–8]. Studies estimated that up to 49% of males in Jazan, a region in the southeast of Saudi Arabia, practice the habit, and the figure increases to 62% in Jazan rural areas [9–13]. Apart from the reported systemic effects of qat chewing [14], the habit is claimed to have deteriorating effects on oral soft and hard tissues [15, 16], however, what has been published on this topic is scarce and conflicting.

One example of these deteriorating effects of qat chewing is dental caries –the most prevalent, multifactorial, chronic human disease [17]. Although it is mainly an infectious disease, many overlapping and interacting-with each other predisposing factors play a role. Habits, whether good or bad, are essential components of these factors. Qat chewing, smoking, smokeless tobacco use, vaping,…etc are examples of the bad habits reported to predispose to dental caries. However, evidence on the potential association between qat chewing and dental caries is lacking owing to the conflicting results obtained by the previous studies [17–22]. Therefore, this study sought to assess the potential association of qat chewing with dental caries in a sample of Jazan population.

This cross sectional study was conducted during the first and second semesters of the 2018–2019 academic year. The study protocol was approved by the Scientific Research Committee, College of Dentistry, Jazan University, Saudi Arabia (CODJU-181291), and was conducted with strict adherence to The Declaration of Helsinki on Medical Research involving Human Subjects [23].

The population frame was all dental patients who attended the outpatient dental clinics during the above mentioned period. The study aimed to include a sample of qat chewers (QC) and non qat chewers (NQC) given that they were 20–50 years old and medically fit males. With regard to QC group, they had to chew qat for at least five years, three to seven days a week, and at least two hours each time in order to be defined as QC. Smokeless tobacco users were decided to be excluded in order to minimize the cofounding factors. The sample size was calculated using G*power program Version 3.1.9.6 to detect a clinically significant difference in DMFT score between QC and NQC. The following scenario was proposed: DMFT score for QC and NQC are 6 ± 4 and 4.5 ± 3 (the difference = 1.5), and the values of significance and power of this two-tailed scenario were set at 0.05 and 0.8, respectively. The yielded total sample was 178 divided into two equal groups (QC and NQC, 89 each). For more precision, we included 200 subjects (100 QC and 100 NQC).

The clinical examination was done by three pre-calibrated examiners in outpatient clinics on dental chair using the dental examination set. The Decayed, Missing, and Filled Teeth (DMFT) index was used to determine the dental status. Clinical training on scoring the teeth based on DMFT was conducted by a specialist (EH). Then calibration was done on ten subjects (not included in the sample) to make sure they had the necessary skill to detect the caries and correctly record the DMFT index. In brief, the teeth were washed with water spray with using suction, and dried with air spray and cleaned with gauze. Then DMFT was determined for each tooth and recorded into a specialized form included with an interview form which was designed to collect - in addition to DMFT - information on age, place of residence (rural or urban), education level, and oral hygiene practices. The form also covered the personal history of qat chewing (years since commencing chewing habit, and frequency of chewing in term of days per week, and hours per session). The Care Index (CI = [F/D + M + F]×100), Restorative Index (RI = ([F/D + F] ×100) and Treatment Index ([TI = F + M/D + M + F] ×100) were calculated.

Data were obtained as exel file from which it was imported into SPSS software version 21 (IBM Corp., Armonk, NY, USA) which was used for statistical analyses. The outcome variables (DMFT with its individual components, CI, RI, and TI) were assessed for normal distribution using Kolmogorov-Smirnov test. As the data were normally distributed, comparisons between both subgroups were done using parametric test (independent t-test). Multiple linear regression analyses were further conducted to stand on the independent determinants of these outcomes among the study sample.

The QC were slightly older (36.55 ± 8.74 years) than NQC (32.96 ± 8.49 years; P = 0.004). QC and NQc were equally distributed by residency area (urban versus rural; P = 0.5) but not equally distributed according to the education levels: NQC with university and higher education were more than QC (35% versus 14%; P = 0.001). Similarly, more NQC reported brushing their teeth than QC did (56% versus 35%; P = 0.004). However, no statistical difference was found regarding dental flossing (11% of NQC 5% of QC; P = 191). Most of the QC reported practicing the habit for > 5–15 years (36%) and > 15 years (38%) since onset of the habit, for > 2–4 hours (30%) and > 4 hours (38%) per a session, > 3 times a week (61%). Fifty-seven of the QC (57%) reported chewing in the left side (Table 1).

Table 1

Demographic and qat chewing characteristics of the study sample.
Variables		Qat Chewers; n (%)	Control (Non-Qat Chewers); n (%)	P value
Residency	Urban	41 (41)	40 (40)	0.5
Residency	Rural	59 (59)	60 (60)	0.5
Education	Illiterate	3 (3)	4 (4)	0.001
	Less than high school	31 (31)	14 (14)
	High school	52 (52)	47 (47)
	University	14 (14)	33 (33)
	High educaion	0 (0)	2 (2)
Tooth brushing	Yes	35 (35)	56 (56)	0.004
Tooth brushing	No	65 (65)	44 (44)	0.004
Flossing	Yes	5 (5)	11 (11)	0.191
Flossing	No	95 (95)	89 (89)	0.191
Chewing time	5–10 years	26 (26)	NA	NA
	> 10–15 years	36 (36)	NA
	> 15 years	38 (38)	NA
Chewing period	2 hours	32 (32)	NA	NA
	> 2–4 hours	30 (30)	NA
	> 4 hours	38 (38)	NA
Chewing frequency	2 times per week	26 (26)	NA	NA
	3 times per week	13 (13)	NA
	> 3 times per week	61 (61)	NA
Chewing side	Right	43 (43)	NA	NA
Chewing side	Left	57 (57)	NA	NA
Age; mean ± SD		36.55 ± 8.74	32.96 ± 8.49	0.004
NA: Not Applicable.

With regard to the dental caries experience, DMFT was statistically higher among QC (9.15 ± 5.87) compared to NQC (6.7 ± 4.58; P = 0.001). Most of the fraction of the DMFT index was attributed to the D component, which was statistically higher among QC compared to NQC (5.91 ± 5.16 and 3.73 ± 3.62, respectively, P = 0.001). The M and F components were not statistically different between groups (P = 0.111 and 0.267, respectively. Similarly, were the CI, RI, and TI (P = 0.08, 0.101, 0.081, respectively). Table 2 provides more details.

Table 2

DMFT, its individual components, CI, RI, and TI by qat chewing
Variables	Qat Chewers; mean (SD)	Control (Non-Qat Chewers); mean (SD)	P value
Decay	5.91 (5.16)	3.73 (3.62)	0.001
Missing	1.67 (3.62)	1 (2.09)	0.111
Filling	1.57 (2.32)	1.97 (2.83)	0.276
DMFT	9.15 (5.87)	6.7 (4.58)	0.001
CI (%)	20.41 (28.32)	28.48 (34.62)	0.08
RI (%)	23.85 (32.11)	32.19 (37.13)	0.101
TI (%)	34.36 (32.64)	43.17 (36.37)	0.081
CI: Care index; RI: Restorative index; and TI: Treatment index (see the text for more details).

Table 3 presents the result of the multiple linear regression analyses which revealed that qat chewing and age, individually or together, were the independent determinants for the dental Decay, Missing, DMFT and TI. Qat chewing explained 5.2% of the variability of the D component (R² = 0.052; P < 0.001), and 7.2% when combined with age (R² = 0.072; P = 0.012). Qat chewing and age together explained 10.2% of the variability of the TI (R² = 0.102; P = 0.009); qat chewing alone explained 2.8%, leaving 7.2% for age (R² = 0.072; P < 0.001). Qat chewing explained 4.7% of the variability of the DMFT (R² = 0.047; P = 0.001), while the age alone explained 14.6% of the M component (R² = 0.146; P < 0.001).

Table 3

Independent determinants of DMFT, its individual components, CI, RI, and TI.
Dependent Variable	Determinants	B (95% CI)	Adjusted R²	P value
Decay	Qat Chewing	-2.51 (-3.76 - -1.26)	0.052	< 0.001
Decay	Age	-0.09 (-0.16 - -0.02)	0.072	0.012
Missing	Age	0.131 (0.087–0.175)	0.146	< 0.001
DMFT	Qat Chewing	-2.45 (-3.92 - -0.982)	0.047	0.001
TI	Age	1.235 (0.692–0.1.777)	0.074	< 0.001
	Qat Cheweing	12.874 (3.288–22.46)	0.102	0.009
TI: Treatment index (see the text for more details).

There is growing evidence links qat chewing with many systemic and oral diseases. However, the evidence on the habit association with development of dental caries is conflicting, with many study supported this notion [18, 19, 24–26] while others didn’t [15, 20, 21]. In light of such a controversy, this study aimed to fill the gap. The results, based on the bivariate and multivariate analyses, support the notion that qat chewing is associated with higher dental caries experience. It must be emphasized that the multivariate statistical model adjusted for the other confounding factors like education and oral health behaviors, a matter which ensures revealing only the effects of the real factors, which were age and qat chewing in our study. Collectively, this confirms that qat chewing diminishes the potential positive effects of high levels of education and the good oral health practices. In our study, the education was statistically significant in the univariate analysis, and this is highly supported by many previous studies [21, 27–29]. Similarly, the univariate analysis revealed that the tooth brushing was significantly more among NQC than QC. Although it is a foregone conclusion that good oral heath practices are protective against dental caries [30, 31], the multivariate analysis didn’t support this in our study. Taken together confirms, at least theoretically, that qat chewing negatively nullifies the positive effects of these factors. Overall, the study provides significant results require a serious attitude and prompt intervention from the authorities.

How qat chewing exerts such deleterious effects is unknown: whether it is due to the chemical composition of qat, mechanical irritation, and/or indirect modifying effects on the positive factors is a hot topic for future research. What matters more, however, is how to tackle this habit. In other meaning how to persuade the current QC to give up and prevent NQC indulging into the habit.

Up to 65% and 56% of DMFT scores among QC and NQC were attributed to the Decay (D) component. This reflects the extent to which that the included subjects, more specifically QC, were indifferent regarding seeking dental treatment. This is confirmed more through the Missing (M) component, which was significantly higher among QC, and through Filling (F) component, which was higher among NQC, although insignificant. Further confirmation comes from the care, restorative, and treatment indices (CI, RI, and TI) which were, although insignificantly, higher among NQC, reflecting they had sought treatment more frequently than QC did.

Although the statistical models revealed significant roles for qat chewing and age, individually or together, the explained variabilities remain small, ranging from 4.7–14.6%, indicative of existence of other factors, not included in the study, play roles. Indeed, dental caries is a multifactorial disease where so many biological, microbiological, environmental, socioeconomic, and behavioral factors interact with each to ultimately cause dental caries [32, 33]. However, we have to confirm that we included two major factors which are well known to be associated with dental caries as indicated above: education, and oral health behaviors, namely toothbrushing and flossing. Irrespective they were significant determinants of dental caries in univariate analysis, they lost their effects upon statistical adjusting with multivariate analysis, suggestive they are confounding factors dominated by qat chewing and age. This may mean either many of the respondents, more specifically QC, misleadingly reported higher education levels and positive oral health practices in order to reflect positive image on their selves, a matter which may contaminate the results, or that qat chewing exerts highly negative effects that surpass, and even diminish, the positive effects of these factors.

The study has a few limitations worthy to mention. First, the sample size was small, although we had calculated it in advance, and we could find both statistical and clinical differences, meaning that larger sample was not required to achieve the same results, although undoubtedly would have been better, and we recommend it for future research. Second, the study didn’t include females due to difficulties in finding females who admit chewing qat. Third, the age of the subjects was restricted to 20–50 years. However, we aimed to lessen the effects of age and associated systemic diseases on the oral cavity. Worthy to note that all included subjects were medically fit. Fourth, the gingival/periodontal health was not assessed, although this would have been essential given the conflicting results with which the medical literature is saturated. Finally, the dental examination was done by three dental interns, a matter which may raise doubt regarding the reliability of measurement. However, we confirm that the examiners were well trained and pre-calibrated. They only commenced examination once they obtained similar results from 10 subjects examined under supervision for the purpose of calibration.

To sum up, qat chewing habit has a detrimental impact on dental health. More specifically, it is associated with higher dental caries and missing teeth, and a lower treatment index.

Acknowledgment:

The study was a dental internship project, a partial requirement for completion of one-year dental internship period.

Funding:

The study is self-funded.

Conflict of Interests:

The authors have no conflict of interests to declare.

Availability of data:

The corresponding author confirms that the data will be made available upon justified request.

-Ethics approval and consent to participate

This cross-sectional study was conducted during the first and second semesters of the 2018–2019 academic year. The study protocol was approved by the Scientific Research Committee, College of Dentistry, Jazan University, Saudi Arabia (CODJU-181291), and was conducted with strict adherence to The Declaration of Helsinki on Medical Research involving Human Subjects

* Informed consent was obtained from all subjects and/or their legal guardian(s).

-Consent for publication

Not Applicable
-Availability of data and materials

The corresponding author confirms that the data will be made available upon justified request

-Competing interests

All authors declare no conflict of interest
-Funding

The study is self-funded.

-Authors' contributions

Esam Halboub: Concept, data analysis and approval of the manuscript

Abdulwahab Ahmed Alamri: Data collection

Ghazi Kamili: Data collection

Ahmed Shaher Alqahtani: Drafting, writing and reviewing the manuscript

-Acknowledgements

The study was a dental internship project, a partial requirement for completion of one-year dental internship period.

-Authors' information (optional)

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Table 1. Demographic and qat chewing characteristics of the study sample.

Variables		Qat Chewers; n (%)	Control (Non-Qat Chewers); n (%)	P value
Residency	Urban	41 (41)	40 (40)	0.5
Residency	Rural	59 (59)	60 (60)	0.5
Education	Illiterate	3 (3)	4 (4)	0.001
	Less than high school	31 (31)	14 (14)
	High school	52 (52)	47 (47)
	University	14 (14)	33 (33)
	High educaion	0 (0)	2 (2)
Tooth brushing	Yes	35 (35)	56 (56)	0.004
Tooth brushing	No	65 (65)	44 (44)	0.004
Flossing	Yes	5 (5)	11 (11)	0.191
Flossing	No	95 (95)	89 (89)	0.191
Chewing time	5 - 10 years	26 (26)	NA	NA
	> 10 – 15 years	36 (36)	NA
	> 15 years	38 (38)	NA
Chewing period	2 hours	32 (32)	NA	NA
	> 2-4 hours	30 (30)	NA
	> 4 hours	38 (38)	NA
Chewing frequency	2 times per week	26 (26)	NA	NA
	3 times per week	13 (13)	NA
	> 3 times per week	61 (61)	NA
Chewing side	Right	43 (43)	NA	NA
Chewing side	Left	57 (57)	NA	NA
Age; mean ± SD		36.55 ± 8.74	32.96 ± 8.49	0.004

NA: Not Applicable.

Table 2. DMFT, its individual components, CI, RI, and TI by qat chewing

Variables	Qat Chewers; mean (SD)	Control (Non-Qat Chewers); mean (SD)	P value
Decay	5.91 (5.16)	3.73 (3.62)	0.001
Missing	1.67 (3.62)	1 (2.09)	0.111
Filling	1.57 (2.32)	1.97 (2.83)	0.276
DMFT	9.15 (5.87)	6.7 (4.58)	0.001
CI (%)	20.41 (28.32)	28.48 (34.62)	0.08
RI (%)	23.85 (32.11)	32.19 (37.13)	0.101
TI (%)	34.36 (32.64)	43.17 (36.37)	0.081

CI: Care index; RI: Restorative index; and TI: Treatment index (see the text for more details).

Table 3. Independent determinants of DMFT, its individual components, CI, RI, and TI.

Dependent Variable	Determinants	B (95% CI)	Adjusted R²	P value
Decay	Qat Chewing	-2.51 (-3.76 - -1.26)	0.052	< 0.001
Decay	Age	-0.09 (-0.16 - -0.02)	0.072	0.012
Missing	Age	0.131 (0.087 – 0.175)	0.146	< 0.001
DMFT	Qat Chewing	-2.45 (-3.92 - -0.982)	0.047	0.001
TI	Age	1.235 (0.692 – 0.1.777)	0.074	< 0.001
	Qat Cheweing	12.874 (3.288 – 22.46)	0.102	0.009

TI: Treatment index (see the text for more details).

No competing interests reported.

Dental Caries experience among qat chewers in Jazan population, Saudi Arabia

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Abstract

Aims

Materials and Methods

Results

Conclusion

Introduction

Materials And Methods

Results

Discussion

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References

Tables

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